History Management

A list of inactive or past health conditions (“History”) appears in all charts in all contexts. A patient's health history is categorized into Medical, Surgical, Family, Social and Device & Implant categories. These are grouped together in the "History" activity that can be opened within any patient chart and any encounter. If not a default activity, users can make the History activity always appear among the available tabs within open charts.

It may not be obvious whether a health condition, event or experience should be listed as an active problem on the patient's Problem List, or whether it instead belongs on one of the history lists. Indeed, that the same entry can be in both places may add to the confusion.

As emphasized in Problem List Management, users should feel free to move items back and forth between problem and history lists. Embedded tools make this easy. Indeed, promotion of history items to active problems, and demotion of problems to the history, should be a part of regular problem list reconciliation, a Connect Care minimum use norm. In general health matters should be allocated according to the following simple guides:

  • Problem: A condition belongs on the Problem List if it is current and active, as reflected by associated diagnostic, therapeutic, rehabilitative, palliative or other interventions. Accordingly, if a patient is on a medication for a particular health condition, the condition should be listed on the Problem List. If a health condition could affect or be affected by other Problem List entries, then it belongs on the Problem List, at least as long as the affected problem is active.

  • History: A condition that no longer impacts, or is impacted by, a patient’s current care should be resolved (removing to the past list), or moved to the Medical, Family or Surgical History.

  • Device: An attached or implanted medical device that plays a central role in the management of an active problem or is an ongoing result of a prior medical or surgical intervention should be documented in the Devices and Implants section of the History activity. Sometimes devices are associated with health problems (such as infection), when it then becomes appropriate to highlight the device complication as an active problem.

This section focuses on history documentation skills consistent with Connect Care Problem List Norms.

Medical History

Surgical History

Family History

Device & Implant History

Medical or surgical devices may be attached to or implanted within a patient. These are important to document in a structured way, as this facilitates use of the information in clinical decision support and awareness during relevant interventions. For example, that a patient has an artificial hip matters when selecting the type and duration of antimicrobial therapy for septic arthritis; that a patient has an inferior vena cava filter is essential to know when considering interventional radiology procedures or angiography.

The "Devices & Implants" section of "History", "Problem List" and "Problem Oriented Charting" activities gives easy access to tools for adding, updating and removing relevant information. The same functionality can be accessed by doing a global (chart) search for "Implant" and then selecting "Jump to implants".

The device properties interface supports capture of precise details. This matters most for devices requiring regular surveillance until an anticipated explantation date. For other objects, it is sufficient to indicate the type, name, status and insertion date of the implant. If no appropriate type category appears in the available pick-list, then that field can be left empty and a descriptive name entered for the device or implant of interest.

Device and implant data is incorporated into standard documentation objects (e.g., admission history & physical, discharge summary) and can be added to other documentation with the ".DEVICEHXT" SmartLink.

More Information